A nurse is assisting in the care of a client who is 36 weeks of gestation and reported to the clinic for a routine visit.
Which of the following findings should the nurse report to the provider?.
Blood pressure.
Cerebral manifestations.
Fetal heart rate.
Respiratory rate.
Deep tendon reflexes.
Gastrointestinal assessment findings.
The Correct Answer is C
Choice A reason:
Blood pressure. The nurse does not need to report the blood pressure because it is not mentioned in the given information that there is any abnormality or concern related to the client's blood pressure. Therefore, it is not a priority finding to report.
Choice B reason:
Cerebral manifestations. There is no mention of cerebral manifestations in the nurse's notes. Since there are no reported neurological symptoms or abnormalities, the nurse does not need to report cerebral manifestations to the provider.
Choice C reason:
Fetal heart rate. The nurse should report the fetal heart rate to the provider because it is an essential parameter to monitor during prenatal care. A normal fetal heart rate ranges from 110 to 160 beats per minute, and in this case, the fetal heart rate is 158/min, which falls within the normal range. However, it is still necessary to inform the provider about this vital sign for documentation and reassurance.
Choice D reason:
Respiratory rate. The respiratory rate is not mentioned in the nurse's notes, and there are no indications of any respiratory issues or concerns. Therefore, it is not necessary to report the respiratory rate to the provider based on the information provided.
Choice E reason:
Deep tendon reflexes. The nurse notes that the patellar reflex is 3+ and clonus is negative. These findings are within the normal range and do not require reporting to the provider.
Choice F reason:
Gastrointestinal assessment findings. The nurse's notes do not mention any abnormal gastrointestinal assessment findings. Since there are no indications of gastrointestinal issues, the nurse does not need to report any gastrointestinal findings to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["6"]
Explanation
The Apgar s core is a s coring s ys tem doctors and nurs es us e to as s es s newborns after they’re born. The Apgar s coring s ys tem is divided into five categories : Activity, Puls e, Grimace, Appearance, and Res piration. Each category receives a s core of 0 to 2 points 1.
Bas ed on the information you provided, the newborn’s 1-min Apgar s core would be calculated as follows :
• Activity: s ome flexion of extremities = 1 point
• Puls e: heart rate 110/ min = 2 points
• Grimace: grimace in res pons e to s uctioning of the nares = 1 point
• Appearance: body pink in color with blue extremities = 1 point
• Res piration: s low, weak cry = 1 point
Adding up the points for each category, the newborn’s 1-min Apgar s core would be 6.
Correct Answer is B
Explanation
Choice A rationale:
Abdominal pain with minimal red vaginal bleeding may not be as concerning as other options. While it could be a sign of placenta previa, it is not as specific or significant as the finding in Choice B.
Choice B rationale:
A large amount of bright red vaginal bleeding without pain is a significant finding that is highly suggestive of placenta previa. Placenta previa occurs when the placenta partially or completely covers the cervix, and vaginal bleeding is a common symptom. The bright red colour indicates active bleeding, and the absence of pain is noteworthy as placenta previa bleeding is typically painless.
Choice C rationale:
Severe abdominal pain with increasing fundal height is not a typical sign of placenta previa. While abdominal pain can be associated with various pregnancy complications, it is not a specific finding for this condition.
Choice D rationale:
Intermittent abdominal pain following the passage of bloody mucus could be related to other issues, such as preterm labor or cervical changes. While bleeding may be present in placenta previa, the pain and passage of mucus are not characteristic features of this condition.
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